Provider Demographics
NPI:1730202466
Name:BALLENGER, JAMES EDWARD (LCSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:BALLENGER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331581
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76163-1581
Mailing Address - Country:US
Mailing Address - Phone:817-975-8015
Mailing Address - Fax:817-361-9958
Practice Address - Street 1:4200 SOUTH FWY STE 2325
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1400
Practice Address - Country:US
Practice Address - Phone:817-975-8015
Practice Address - Fax:817-361-9958
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX238531041C0700X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1594087-01Medicaid
TX159408703Medicaid
TX1594087-01Medicaid